Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

The Effect of Rectal Suppository of Anethum graveolens on the Postpartum Hemorrhage Rate: Evidence from a Single-Blind Clinical Trial Study

Background: Postpartum hemorrhage (PPH) is a leading cause of mortality and morbidity worldwide. Anethum graveolens (dill) is one of the recommended herbs to reduce bleeding. Objectives: This study aimed to evaluate the efficacy of rectal suppository of Anethum graveolens on the postpartum hemorrhage (PPH). Methods: Following a randomized clinical design, 70 eligible pregnant women admitted for vaginal delivery to Umm-al-Banin Hospital in Mashhad (Iran) in 2018 were recruited in this trial. Subjects were selected by available method and randomly assigned into two groups of intervention and control. Both groups, immediately after the delivery, received routine hospital interventions. Instantly after the expulsion of the placenta, the intervention group received the first dose of rectal suppository and the subsequent doses up to five doses at intervals of 30 min. PPH was measured by weighing the blood bags and pads for 4h after labor. Data were collected using a sample selection checklist, demographic and pregnancy information forms, birth, infant, and placenta information forms, and partograph sheets. Data were analyzed by SPSS version 22 using an independent t-test or the Mann-Whitney test. Results: The two groups were homogeneous in terms of mediating variables. The mean bleeding rate at the end of the first fourth after delivery was 306.2 ± 11.2 cc in the control group and 282.4 ± 9.6 cc in the intervention group. Therefore, there was a statistically significant difference concerning post-delivery bleeding between the two groups (P = 0.001). Conclusions: Based on the findings, the rectal suppository of Anethum graveolens could effectively reduce the PPH without any adverse effects. Therefore, this efficient herbal approach is suggested to overcome the PPH.

Interventional radiology for the obstetric patient

PURPOSE OF REVIEW

To discuss the recent results of the use of interventional radiology modalities treating postpartum hemorrhage (PPH).

RECENT FINDINGS

PPH still is a leading cause of maternal morbidity and mortality. An important risk factor for the development of PPH is the placenta accreta spectrum. In patients with placenta accreta, we can use prophylactic balloon occlusion of the common or internal iliac artery or abdominal aorta to prevent PPH. Balloon occlusion of the abdominal aorta seems to ensure better results than balloon occlusion of the iliac artery in terms of blood loss, transfusion rate and hysterectomy rate reduction with a minimal risk of complications. To treat PPH uterine artery embolization can be effective and potentially fertility-sparing, while having a low complication rate.

SUMMARY

The use of aortic balloon occlusion catheters for the prevention of PPH and uterine artery embolization for the treatment of PPH are well tolerated and feasible options for patients with placenta accreta spectrum.

Scaling up interventions: findings and lessons learned from an external evaluation of Niger's National Initiative to reduce postpartum hemorrhage

Background

Niger has one of the highest maternal mortality ratios in Sub Saharan Africa, of which postpartum hemorrhage is the leading cause. In 2014, Health and Development International and the Ministry of Health of Niger launched an initiative to introduce and scale-up three PPH interventions in health facilities nationwide: misoprostol, uterine balloon tamponade, and the non-pneumatic anti-shock garment.

Methods

A two-phase mixed-methods evaluation was conducted to assess implementation of the initiative. Health facility assessments, provider interviews, and household surveys were conducted in May 2016 and November 2017.

Results

All evaluation facilities received misoprostol prevention doses. However, shortages in misoprostol treatment doses, UBT kits, and NASG stock were documented. Health provider training increased while knowledge of each PPH intervention varied. Near-universal uterotonic coverage for PPH prevention and treatment was achieved and sustained throughout the evaluation period. Use of UBT and NASG to manage PPH was rare and differed by health facility type. Among community deliveries, fewer than 22% of women received misoprostol at antenatal care for self-administered prophylaxis. Among those who did, almost all reported taking the drugs for PPH prevention in each phase.

Conclusions

This study is the first external evaluation of a comprehensive PPH program taking misoprostol, UBT, and NASG to national scale in a low resource setting. Although gaps in service delivery were identified, results demonstrate the complexities of training, managing stock, and implementing system-wide interventions to reach women in varying contexts. The experience provides important lessons for other countries as they develop and expand evidence-based programs for PPH care.

Using Interventional Radiology to Treat Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a serious complication of giving birth that can result in death. Interventional radiology allows for the use of uterine artery embolization and transcatheter arterial embolization to prevent and treat PPH. These procedures are minimally invasive options that use the uterine or internal iliac arteries to place either a balloon or embolic material to stop the bleeding. These techniques also can be used as a preventive treatment for women with known placental abnormalities who are at an increased risk of hemorrhaging. This article discusses causes, early recognition, and treatment of PPH. It also discusses nursing care for patients with PPH and presents a case report describing the use of interventional radiology before cesarean delivery for a patient with placenta accreta.

Use of Postpartum Magnetic Resonance Imaging for Diagnosis and Classification of Retained Placenta Tissue

OBJECTIVE

To study the potential application of magnetic resonance imaging (MRI) for classification of retained placental tissue (RPT) in the uterus postnatally.

METHODS

Twenty-two patients with clinically or pathologically proven RPT were studied.

RESULTS

The thickness ratio (D1/D2) of invaded (D1) to normal (D2) myometrium could be categorized into 3 groups (>0.6, 0.1-0.6, and <0.1) correlating with the 3 types of RPT: accreta vera (RPA), increta (RPI), and percreta (RPP) (r = -0.861, P < 0.01). After uterine arterial embolization, the RPT showed lower signal intensity than the myometrium without flow voids on T2-weighted images. Two cases of RPP showed gradual enhancement, except 1 case of infection and 2 cases that did not involve enhancement examinations, whereas 17 cases of RPA and RPI showed early enhancement.

CONCLUSIONS

Magnetic resonance imaging can facilitate diagnosis of RPT severity. Dynamic contrast enhancement can indicate RPT activity and blood supply, thereby ensuring appropriate clinical decision making.

Autologous Blood Transfusion for Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a leading contributor to maternal morbidity and mortality in the United States and globally. Although the rate of PPH is generally decreasing nationally, severity of PPH appears to be increasing, potentially related to the various comorbidities associated with women of childbearing age. There is increasing evidence of risks associated with allogeneic blood transfusion, which has historically been the classic therapeutic approach for treatment to PPH. Pregnant women are particularly susceptible to the implications of sensitization to red cell antigens, a common sequela to allogenic blood transfusion. Autologous blood transfusion eliminates the potential of communicable disease transmission as well as the conceivable threat of a blood transfusion reaction. Recent technological advances allow cell salvage coupled with the use of a leukocyte filter to be used as an alternative approach for improving the outcome for women experiencing a PPH. Modest changes in standard operating procedure and continued training in use and application of cell salvaged blood may assist in minimizing negative outcomes from PPH. Salvaged blood has been demonstrated to be at least equal and often superior to banked blood. We discuss nursing implications for application of this technology for women with PPH. Continued research is warranted to evaluate the impact that application of cell salvage with filtration has on the patient experiencing a PPH.

Longitudinal parallel compression suture to control postopartum hemorrhage due to placenta previa and accrete

OBJECTIVE

To assess the efficacy and safety of longitudinal parallel compression suture to control heavy postpartum hemorrhage (PPH) in patients with placenta previa/accreta.

MATERIALS AND METHODS

Fifteen women received a longitudinal parallel compression suture to stop life-threatening PPH due to placenta previa with or without accreta during cesarean section. The suture apposed the anterior and posterior walls of the lower uterine segment together using an absorbable thread A 70-mm round needle with a Number-1 absorbable thread was used. The point of needle entry was 1 cm above the upper margin of the cervix and 1 cm from the right lateral border of the lower segment of the anterior wall. The suture was threaded through the uterine cavity to the serosa of the posterior wall. Then, it was directed upward and threaded from the posterior to the anterior wall at ∼1-2 cm above the upper boundary of the lower uterine segment and 3-cm medial to the right margin of the uterus. Both ends of the suture were tied on the anterior aspect of uterus. The left side was sutured in the same way.

RESULTS

The success rate of the procedure was 86.7% (13/15). Two of 15 cases were concurrently administered gauze packing and achieved satisfactory hemostasis. All patients resumed a normal menstrual flow, and no postoperative anatomical or physiological abnormalities related to the suture were observed. Three women achieved further pregnancies after the procedure.

CONCLUSION

Longitudinal parallel compression suture is a safe, easy, effective, practical, and conservative surgical technique to stop intractable PPH from the lower uterine segment, particularly in women who have a cesarean scar and placenta previa/accreta.

Uterine folding hemostasis: a simpler and safer technique for controlling atonic postpartum hemorrhage

OBJECTIVE

To observe the efficacy and safety of a uterine folding hemostatic technique in controlling atonic postpartum hemorrhage (PPH) during cesarean delivery.

METHODS

Thirty-nine women with severe postpartum bleeding from uterine inertia, which did not react to conventional initial management protocols, underwent a uterine folding hemostasis. The procedure was to fold the uterine fundus onto the anterior wall of the corpus uterus using an absorbable suture that thread tautly through the inner myometrial layer of the uterus 1-3 cm below the fundus (not entered into uterine cavity) and 1-2 cm above and below the CS incision (entered into uterine cavity 2-4 cm medal to bilateral border of the uterus).

RESULTS

The technique was sufficient to stanch bleeding immediately in 32 patients (82.1 %). Seven women underwent hypogastric arteries ligation (1 case) or uterine arterial embolization (6 cases) because of continuous bleeding after the procedure. There were no morbidities or abnormalities of the uterus in these 32 patients. Eight women had pregnancies after this hemostasis and the others lacked the desire for future pregnancy.

CONCLUSION

Uterine folding hemostasis is a simple, safe and effective technique to control the atonic PPH.

The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage

Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.

The Effect of Combined Oxytocin-Misoprostol Versus Oxytocin and Misoprostol Alone in Reducing Blood Loss at Cesarean Delivery: A Prospective Randomized Double-Blind Study

PURPOSE

To compare the effect of combined oxytocin-misoprostol versus oxytocin and misoprostol alone in reducing blood loss at cesarean delivery.

METHODS

One hundred fifty patients of 18-40 years with singleton term pregnancies scheduled for cesarean section under spinal anesthesia were recruited in a prospective double-blind randomized clinical trial to one of the three following groups to receive 20 IU infusion of oxytocin (group O), 400-µg sublingual misoprostol tablets (group M) or 200-µg misoprostol plus 5 IU bolus intravenous oxytocin (group MO) after delivery. The hemoglobin level before surgery and 24 h after surgery, the need for additional oxytocic therapy, and the incidence of adverse effects were recorded.

RESULTS

The mean blood loss during surgery was significantly lower in group MO compared to other groups (P = 0.04). Comparison of mean arterial pressure (P = 0.38) and heart rate (P = 0.23) changes during spinal anesthesia and surgery failed to reveal any statistically significant differences between all groups through repeated measure analysis.

CONCLUSION

The use of combined lower dose of misoprostol-oxytocin significantly reduced the amount of blood loss during and after the lower segment cesarean section compared to higher dose of oxytocin and misoprostol alone, and its use was not associated with any serious side effects.